Prevalence of Discrimination and the Association Between Employment Discrimination and Health Care Access and Use — National HIV Behavioral Surveillance Among Transgender Women, Seven Urban Areas, United States, 2019–2020

Discussion

Seven in 10 transgender women experienced transphobic discrimination, and one in three reported employment discrimination during the past year. Having trouble getting a job because of being transgender was associated with poor social determinants of health and lower health care access and use, including gender-affirming procedures.

The prevalence of discrimination in NHBS-Trans had certain similarities to and differences from previous studies, including the 2015 U.S. Transgender Survey (USTS) (3). Compared with USTS participants, NHBS-Trans participants reported similar prevalence for employment discrimination (32% NHBS-Trans versus 30% USTS); higher prevalence of bathroom discrimination (22% versus 9%), poorer treatment in businesses (39% versus 31%), verbal abuse (59% versus 12%), and physical abuse (27% versus 1%); and lower prevalence of housing discrimination (13% versus 23%) and health care discrimination (11% versus 33%). These differences might be partially explained by the sociodemographic composition of these two surveys: participants in the NHBS-Trans sample were predominantly Black or Hispanic and had lower SES, whereas participants in the USTS sample were predominantly White and had higher SES. In addition, during 2015–2019, transgender persons reported increased discrimination and minority stress because of a political climate that was increasingly hostile toward transgender persons (20). Finally, NHBS-Trans and USTS had differences in their questionnaires.

Employment discrimination occurs at the overlapping nexus of poverty, homelessness, incarceration, health insurance, disability, food insecurity, and survival sex work. These issues are interconnected. When economically marginalized transgender women are refused employment, this refusal cyclically contributes to economic hardships and might lead them to engage in survival sex work (8) and potentially incarceration, increasing their chances of facing further employment discrimination. For many persons, sex work might be their main form of employment, and employment discrimination also might occur as a part of sex work; however, that could not be examined in this analysis. In addition, although discriminating against job candidates with a disability is illegal, one third of transgender women who had a disability reported trouble getting a job. Previous studies found that transgender persons with disabilities experience high rates of employment discrimination (21), such as not receiving reasonable accommodations.

Employment discrimination was associated with poorer health care access, including being uninsured, having an unmet medical need because of cost, and never having transgender-specific health care. Private health insurance plans often have more provider choices and higher quality of care (22); therefore, employment might influence a person’s ability and opportunity to choose a gender-affirming provider, which is associated with engagement in care and improved health behaviors (23,24). In addition, having a provider with whom the person is comfortable discussing gender issues is related to pre-exposure prophylaxis use for HIV-negative transgender women (25,26) and engagement in HIV care among transgender women with HIV infection (24). Because transgender women who experienced employment discrimination were more likely to have no health insurance coverage or coverage through Medicaid only, improving health care staff members’ cultural competency and respect in serving transgender patients, regardless of their health insurance coverage, and increasing staff members’ representation of persons of transgender experience in health care settings is important (27).

The majority of transgender women in NHBS-Trans had Medicaid, which is the largest source of insurance coverage for persons with HIV infection (28). Four in 10 transgender women had an HIV-positive diagnosis and half reported having a disability. Therefore, the finding that Medicaid was the most common source of insurance was not unexpected. Employers also might discriminate against transgender women in part because they have low income (29), have an HIV-positive diagnosis (30), or have a disability (21), which is interrelated with qualifying for Medicaid.

The type of health insurance coverage that is available to transgender women is related to employment and disability status. For example, Medicaid can function as a safety net for persons experiencing sudden unemployment (31). Expanding Medicaid could help transgender women without health insurance qualify for Medicaid; however, Medicaid coverage of gender-affirming care varies by state (11,32). These variations can be a barrier for medically necessary health care for transgender persons with low income (33). In NHBS-Trans, most participants lived in states in which Medicaid programs explicitly cover gender-affirming care, with the exception of Georgia and Louisiana (18). This variable is likely a proxy for larger structural factors, such as negative community attitudes toward transgender persons (34), which can influence Medicaid policy in certain states (35). Furthermore, states that have not expanded Medicaid are primarily in the South, which has large numbers of Black and Hispanic residents (36). Historically, Medicaid policy has been shaped by structural racism, which has contributed to health inequities among Black and Hispanic persons (36).

Most transgender women visited a health care provider or currently use hormones; no association for these experiences was found with employment discrimination. Engagement with the health care system is usually necessary for those who desire hormones or other gender-affirming procedures; therefore, transgender women are highly motivated to seek health care and pursue hormone therapy, sometimes even at the expense of other basic needs (37,38). To achieve their transition goals, certain transgender women might even seek nonprescription hormones, which can be dangerous and unregulated (39,40), or ration prescription hormones because of cost (41). Improving health insurance coverage of gender-affirming care across all states could help protect transgender women from pursuing dangerous alternatives to prescription hormones. However, obtaining gender-affirming procedures without health insurance is more difficult; thus, the relation of an unmet need for gender-affirming procedures with employment discrimination is notable, which might be a structural barrier to health care access. Transgender women possibly have lower access to gender-affirming procedures in part because of employers refusing to hire them, and therefore being uninsured or inadequately insured.